Sexuality and older people

Much of the literature on sexuality in elderly people focuses on sexual problems, leaving clinicians with the impression that older adults have either dismal or non-existent sex lives. Few data are available on “normal” sexuality in elderly people, let alone the entire spectrum of sexual expression including optimal sexuality.1 Beckman and colleagues’ linked study makes a welcome contribution to the limited literature on sexuality in older people.2 A major contribution of Beckman and colleagues’ study is that it focuses on sexual attitudes and behaviour in a sample of people—not patients—who are not seeking treatment for sexual dysfunction or attending a general medical clinic. The methodology is strong, using consistent interviewing techniques over a 30 year period to produce four comparable sets of cross sectional data from 1971 to 2001. Current knowledge suggests that sexual functioning and frequency decline with age and that sex decreases in importance over time.3 The existing literature emphasises the widespread prevalence of sexual difficulties in men and women.4 5 In contrast, Beckman and colleagues provide good news—sex is an important and positive part of the lives of their 70 year old participants, and more so for the current cohort of men and women than for their predecessors in 1971. Although these data are invaluable, the study does have limitations. Sexual activity was defined as sexual intercourse, and the researchers’ questions about same sex activities and self stimulation were discontinued after 1971 for fear of offending participants. The study reports that subjective sexual satisfaction is increasing, especially in women, even if sexual dysfunctions are present. Some dysfunctions such as female anorgasmia and erectile dysfunction are decreasing, whereas others such as ejaculatory dysfunction in men have increased over the past 30 years. The authors speculate that the decrease in erectile dysfunction in 70 year old men may result from the availability of phosphodiesterase type 5 inhibitors. Male sexual dissatisfaction and ejaculatory dysfunction increased in the latest cohort. One interpretation is that older men are “performing” better sexually thanks to erectogenic drugs, but enjoying themselves less, thus the difficulty in male orgasm. The meaning of these findings is worthy of further investigation. Attitudes to sexuality seem to be converging in men and women even though some behaviours remain strikingly constant. Beckman and colleagues seemingly link the increasingly early sexual debut seen over the past 30 years with increasingly positive attitudes to sexuality over time. The implication is that a generation’s sexual change—perhaps linked to the sexual revolution of 1965-75—is evident in this latest cohort of 70 year olds in 2001. Yet, interestingly, both men and women continue to blame men when sexual intercourse ceases between them. This finding has been consistent for 40 years.6 7 Perhaps some aspects of heterosexual relationships are so deeply ingrained that they are more resistant to change. Even if women seem to be coming into their own sexually—and more satisfied than ever in the latest cohort—years of men being in charge of “making the first move” in adolescent sexual encounters in the 1940s and during marriage in early adulthood in the 1950s and 1960s has led to the expectation that men remain responsible for making sex happen. Thus, attributing the responsibility for the frequency or lack of sex to men continues. Perhaps the findings are a manifestation of the time lag between a change in attitude and the ultimate shift in sexual behaviour patterns in heterosexual couples. Clinicians should be sensitive to this mindset when probing into patients’ concerns over sexual frequency, desire, initiation, satisfaction, and their meanings to all parties. What are the implications of these findings for clinical practice? Doctors in general are known to be uncomfortable about asking patients questions about their sex lives. This is particularly so when the patients’ personal characteristics differ from their own (for example, their sex, age, sexual orientation).8 9 This may be especially disadvantageous when dealing with elderly patients who are already assumed to be invisible and post-sexual by society. Such people may be even less likely than most to approach their doctors with sexual problems and concerns, although research shows that most people hope that their doctors will approach them.10 Given that sex plays an increasingly valuable role in the lives of older men and women, Beckman and colleagues’ study reinforces the dictum that doctors should ask—and be trained to ask—every patient, regardless of age, “Any sexual concerns?”9 Doctors are well placed to normalise and affirm the value of fulfilling sexual relations for the wellbeing of older patients.

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